Aims. Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a
Aims. The aim of this study was to explore why some
Aims. This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial
Aims. The aim of this study was to estimate the 90-day risk of revision for periprosthetic femoral fracture associated with design features of cementless femoral stems, and to investigate the effect of a collar on this risk using a biomechanical in vitro model. Materials and Methods. A total of 337 647 primary total hip arthroplasties (THAs) from the United Kingdom National Joint Registry (NJR) were included in a multivariable survival and regression analysis to identify the adjusted hazard of revision for periprosthetic fracture following primary THA using a cementless stem. The effect of a collar in cementless THA on this risk was evaluated in an in vitro model using paired fresh frozen cadaveric femora. Results. The prevalence of early revision for periprosthetic fracture was 0.34% (1180/337 647) and 44.0% (520/1180) occurred within 90 days of surgery. Implant risk factors included: collarless stem, non-grit-blasted finish, and triple-tapered design. In the in vitro model, a medial
Abstract. Objective. To estimate the effect of
The
Aims. In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral
Aims. Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA). Methods. A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure. Results. The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the
Total hip arthroplasty (THA) allows patients to return to an active lifestyle. Unfortunately one of the more common complications of cementless THA is a fracture of the greater trochanter (GT) or the
Introduction. Segmental defects of the femur present a major problem during revision hip arthroplasty. In particular,
The
Background. Post-operative periprosthetic femoral fractures (PFF) are a devastating complication associated with high mortality and are costly. Few risk factors are modifiable apart from implant choice. The design features governing risk of PFF are unknown. We estimated the 90-day risk of revision for PFF associated with design features of cementless femoral stems and to investigate the effect of a collar on early PFF risk using a biomechanical in-vitro model. Patients, materials and methods. 337 647 primary THAs from the National Joint Registry (UK) were included in a multivariable survival and regression analysis to identify the adjusted hazard of PFF revision following primary THA using cementless stems. The effect of a collar in cementless THA on early PFF was evaluated in an in-vitro model using paired fresh frozen cadaveric femora. Results. Prevalence of PFF revision was 0.34% (1180/337647) and 44.0% occurred (520/1180) within 90 days of surgery. Implant risk factors included: collarless stem, non grit-blasted finish and triple tapered design. In the in-vitro PFF model a medial
Metal meshes are used in revision surgery of the hip to contain impacted bone grafts in cases with cortical or
Background: The
Resorption of the
Resorption of the
Between January 1990 and October 2000, 108 total hip arthroplasties using a cemented polished titanium stem and a cemented ultra-high molecular weight polyethylene (UHMWP) cup were performed at our hospital. Because during routine follow-up visits we noted instances of resorption of the
We have previously reported on early lytic lesions occurring when collared titanium prostheses are used. Previous finite element analysis studies (FEAs) showed that lytic lesions of the
A consensus regarding management of calcaneal fractures eludes orthopaedic surgeons. While operative treatment has gained more acceptance, surgical morbidity remains high. We undertook a retrospective review of early complications and radiological outcomes following internal fixation of calcaneal fractures in our unit over 15 months. A consecutive series of 33 patients who underwent fixation of the
Introduction and Aims: Rapidly progressive lytic lesions of the
The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the ‘French paradox’ principles through the Hueter anterior approach (HAA) in patients older than 70 years. From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance.Aims
Methods
Purpose: The success of humeral head replacement following fracture is reliant on several factors, one of which is version. The correct humeral version (HV) is highly variable, and is patient and side dependent. In the setting of fracture, there is no intra-operative landmark to guide the surgeon as to the anatomic version. This study has examined computed tomography (CT) of the shoulder and compared the HV to the metaphyseal version (MV) to evaluate reliability in predicting the anatomic version. Method: A retrospective review of 50 shoulder CT scans was carried out. Patients were excluded if the anatomy prevented HV or MV evaluation. The HV and MV was measured by 2 independent evaluators. Inter and intra-rater reliability was performed. Results: There were 27 right and 23 left shoulder CT’s reviewed. The mean age of patients was 45.3 (range 13–85). The difference between the MV and HV was approximately 2.8 (95% CI 0.63–5.1). Inter and intra-rater reliability was 0.966 and 0.984, respectively. Conclusion: Determining the version of the humeral head in the setting of fracture is difficult and highly inaccurate. The biceps groove has been previously cited as a landmark for arthroplasty position, however, given the anatomic variability, version may be miscalculated. We have demonstrated the medial
Aim: To evaluate long term effects of stress shieldieng phenomenon after cementless total hip arthroplasty. Materials-Methods: 80 female pts with OA were randomly allocated in 4 groups according to the type of the cementless stem which was primarily implanted (A-Zwey-Muller,B-Corail,C- Optifix,DAutophor900S). BMD changes of the operated hip (in seven zones), of the operated, contralateral normal hip and of the Lumbar spine were measured pre-op, at 2, 8 and 12 months and every year thereafter. Results: At ten years, 72 pts were available for follow up, all with satisfactory clinical and radiological results with no evidence of polyethylene wear or endosteal lysis. In all groups, the greatest reduction of BMD (calcar atrophyzone 7) was observed at the 2nd post-op year (A:24%, B:8%, C:14.8%, D:18.5%). In all groups, the greatest increase (zone 4) of BMD was also observed at the 2nd post-op year (A7%, B2%, C2.5%, D6.3%). In all groups a similar pattern of slow but progressive recovery of bone mineral density changes after the 3rd year was observed in both zones, approaching baseline values at 10 years in all groups. Preoperative lumbar BMD (osteopenia), body weight, sex and height were not statisticaly correlated to
Chronic osteomyelitis of the calcaneus is a frequent problem in a population of diabetic patients, patients with neurologic disorders or bedridden patients with ulcers. Partial calcanectomy is an alternative option which avoid major amputation. The aim of this retrospective study was to determine the effectiveness of partial calcanectomy for treating chronic osteomyelitis of the calcaneux. We conducted a retrospective review of patients who underwent in our department a partial calcanectomy between 2006 and 2015. All patients with a complete set of radiographs and adequate follow-up (minimum 2 years) were included. We reviewed these cases to determine healing rate, microbiological analysis, risk factors of failure (comorbidities), limb salvage rate and survival rate. We analyzed specifically the footwear and the functional subjective evaluation according to the LEFS score (Lower Extremity Functional Scale).Aim
Method
1. The literature on fractures of the postero-superior aspect of the calcaneus is reviewed. 2. The mechanical distinction between "beak" fractures and avulsion fractures is questioned, and the dangers of a purely radiological diagnosis are stressed. 3. When a complete avulsion is suspected on clinical grounds, open reduction should be done.
1. Five cases of avulsion fracture of the calcaneus are reported. 2. The "beak" fracture of the calcaneus is thought to be a variant of the avulsion fracture and not a separate entity. 3. The variable attachment of the calcaneal tendon to the calcaneus is described, and its relationship to the different forms of avulsion fractures discussed. 4. Operative reduction and fixation are appropriate for young and active patients in order to restore full heel-cord function. 5. Attention is drawn to the risk of pressure necrosis of skin overlying a displaced fragment. Early operative correction may be required to prevent skin damage.
1. The clinical aspects of fifty-six patients with rupture of the tendo calcaneus are discussed, and the mechanism of injury is described. 2. Operative repair of the rupture is considered with a study of the results in twenty-eight patients.
1. Twenty patients with congenital short tendo calcaneus are described. 2. All were treated by tendon lengthening and followed up for one and a half to seven years.
We reviewed our experience of tibialis anterior transfer and anterior release for calcaneus deformity in 46 feet of 26 ambulant patients with myelomeningocele. At an average follow-up of 8.4 years (2 to 17.6) there were 89% who had satisfactory results; 64% of the patients having tibialis anterior transfers were able to stand on their toes. Hip abductor power was a good predictor of a functional transfer. Pre-operative trophic ulceration of the heel increased from 3.2% to 33% if surgery was delayed. Secondary deformities, two-thirds of them into valgus, developed in 76% of feet.
The thalamus is the part of the calcaneus that supports the posterior articular facet and continues forward, becoming thinner towards the groove of the sinus tarsi. The main displacements after fracture depend on 1) a primary fracture line dividing the bone into anterior and posterior fragments, and 2) a semilunar fragment in the thalamic region. In the operation advised the sinus tarsi is exposed and the semilunar fragment is reduced by rotation in the opposite direction and is fixed to the medial fragment (the sustenaculum tali not being displaced) by a transverse Kirschner wire. The two main fragments are fixed by an antero-posterior wire. Plaster is applied and is retained for twelve weeks. Weight-bearing is not permitted for the first four weeks. There were no major complications in fifty-eight operations. The anatomical results were good: restoration of the tuber-joint angle by reduction of the semilunar fragment was maintained. The functional results were very satisfactory: permanent disability was slight or mild.
1 . Paralytic talipes calcaneus and calcaneo-cavus are difficult deformities to correct and keep corrected. Many operations have been devised for this purpose. 2. Emslie's operation is a simple procedure by which satisfactory correction can be obtained and maintained. It can be modified to suit individual cases without altering the basic principles of the procedure and is physiologically sound. 3. Illustrative cases are described.
1. In a severe crush fracture of the calcaneus part of the lateral cortex may be displaced to lie under the tip of the lateral malleolus. This may cause local pain and tenderness, either by direct bony abutment or by compression of the peroneal tendons. 2. Such pain is usually relieved by excision of the tip of the lateral malleolus, a minor procedure. 3. Four of the five patients reported were completely relieved of lateral pain, and the fifth has only slight residual discomfort. 4. It is important to be aware of this lesion and not to advise subtalar or triple fusion when simple excision of the tip of the fibula would suffice.
1. A case of ossification and partial rupture of the tendo calcaneus is reported. 2. The possible etiology of the ossification and its relationship to the rupture is discussed.
Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis tumours comprises individual case reports, short case series or literature reviews, with the last large case series in 1973. We retrospectively reviewed the medical notes and imaging for all patients with calcaneal tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed. 38 calcaneal tumours were identified. Male to female ratio 2:1, mean age at presentation 30 with heel pain and swelling, average length of symptoms 9 months. 4 cases present with pathological fracture. 24 tumours benign including 6 unicameral bone cysts, 3 chondroblastoma, 3 PVNS with calcaneal erosion, and a wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewings sarcoma. 1 metastatic carcinoma. Tumours of the calcaneus frequently are delayed in diagnosis due to their rarity and lack of clinician familiarity. They are more common in men and have a 1 in 3 risk of malignancy, covering a wide variety of lesions. Outcome is dependent on early diagnosis, timely surgery and most importantly neo-adjuvant chemotherapy. Diagnosis is often made on plain radiograph but MRI is the gold standard. We present the largest case series of calcaneal tumours, from our experience with the Scottish Bone Tumour Registry. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome.
The Ilizarov fixator used consisted of 2 rings positioned above the ankle joint and a foot plate. 1.5 and 1.8 mm wires were used, as well as 1.8 mm wires with an olive for the reduction of displaced fragments. Under image intensification and distraction the fracture was reduced and the articular surface was restored as close as possible.
Controversy exists regarding the management of intra-articular fractures of the calcaneus. We present medium-term outcome data on 37 consecutive patients who underwent open reduction and internal fixation for comminuted intra-articular calcaneal fractures. Operations were performed by one surgeon, CRW, following CT assessment of the fracture. All procedures were performed using an extensile lateral approach and early physiotherapy was standard. Case notes were reviewed retrospectively between three months and five years post-operatively. Patients were also invited to attend a follow-up clinic where outcomes were assessed using the American Orthopaedic Foot and Ankle Society Hind Foot Score and were questioned regarding on-going problems, change in shoe size and return to work. Complete data is available for 16 patients, with additional information from other patients. Results show average AOFAS scores for type II fractures to be 59/100, type III to be 81/100 and 79/100 for type IV fractures. We have shown low rates of complications – one infection, three patients requiring a change in shoe size and an average return to work of seven months. We have shown good medium-term outcome results for the operative management of displaced intra-articular fractures and to answer our question, we believe we should be operating on them.
The lack of a universal, consistent protocol for the subjective, objective and radiographic evaluation of these injuries has hampered the comparison of results. 45 patients with complex fractures of the calcaneus were included in this prospective study, which was undertaken from July 2003 to December 2005. The fracture classification of Essex-Lopresti was used. We also observed the extent of secondary fracture lines extending from the primary shear line (on axial and external oblique plain radiographs) to establish comminution. The external oblique view for subtalar joint was performed with the patient supine, the knee at about 60 degree of flexion and the limb rotated externally 45 degree with a vertical X ray beam. All of these patients were managed by an external fixator using the principle of ligamentotaxis. Patients were evaluated by AOFAS. We identified two broad patterns of secondary lines on plain X-rays: with anterior secondary fracture lines and with posterior secondary fracture lines. There were 20 cases of tongue type and 25 of joint depression type fracture pattern by the Essex-Lopresti classification. Forty two (93.4%) patients had fractures with posterior secondary fracture line and 3 (6.7%) patients had anterior secondary lines. The calcaneo-cuboid type of anterior secondary line pattern was present in 2 (4.5%) cases, and the plantar type in only 1 (2.5%) case. We observed posterior secondary line Type A pattern in 2 (4.5%) cases, depression / central depression type B in 20 (44.5%) cases, tongue shaped Type C pattern in 16 (36.5%) cases and Type D severely comminuted fracture line pattern in 4 (8.7%) cases.Methods
Results
Böhler’s historical tuber-joint angle of the calcaneus has been used since 1931. Surprisingly, there is a paucity of literature on the topic. The aims of this study were to confirm the normal range for Böhler’s angle and determine the angle with the highest accuracy in the diagnosis of calcaneal fractures. A retrospective cohort study was performed. Data were obtained from The St George Hospital digital Picture Archival and Communication System (PACS) and through a review of medical records. The study cohort comprised 212 consecutive patients diagnosed with calcaneal fractures on CT scan, spanning a five-year period from April 2003 to March 2008. An additional 212 patients with normal lateral foot radiographs were used to determine the normal range. Böhler’s angle was measured by two independent observers on lateral xray using the digital angle tool from PACS. Data were analysed using Stata 8 statistical software package. This is the largest study to our knowledge that examines the diagnostic accuracy of Böhler’s angle in fractures of the calcaneus. Contrary to many texts but true to Böhler’s assertions, the mean Böhler’s angle in patients without calcaneal fracture was 29.4 degrees (95% CI, 28.9–30.0 degrees). In this group there was no difference in Böhler’s angle between male and female patients (p>
.05), left and right feet (p>
.05) or across age (ANOVA, p>
.05). In those patients with calcaneal fractures, a Böhler’s angle below 25 degrees was moderately predictive of calcaneal fracture (sensitivity = 100%, specificity = 82%, PPV = 85%, NPV = 100%, LR+ = 5), an angle below 23 degrees was highly predictive of calcaneal fracture (sensitivity = 100%, specificity = 89%, PPV = 90%, NPV = 100%, LR+ = 9) and an angle below 21 degrees was strongly suggestive of calcaneal fracture (sensitivity = 99%, specificity = 99%, PPV = 99%, NPV = 99%, LR+ = 110). A Böhler’s angle of less than or equal to 20 degrees had the highest diagnostic accuracy as there were only two false negatives and one false positive from a total of 424 patients. A Böhler’s angle of 20 degrees or less is highly accurate in determining the presence or absence of calcaneal fracture. These findings are of particular importance when fracture is uncertain as it gives the surgeon a definitive reference point when using Böhler’s angle for assessment of fracture of the calcaneus.
We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity of the ankle. 11 consecutive patients (13 ankles) fulfilled the inclusion criteria over a 4-year period. All underwent surgical treatment using a flexible two hole plate and screws on the posterior aspect of distal tibial physis. Measurements were done on preoperative, intraoperative screening and 1-year post operative plain AP and lateral ankle radiographs. The anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA) and screw divergence angle (angle subtended by lines passing through the long axis of the screws) were used to assess the deformity correction. A 2 tailed student t-test was carried out on the initial and 1-year post-op measurements to determine statistical significance with a p value <0.05 considered as significant There were 10 residual clubfoot deformities, 2 post-traumatic deformities and 1 spinal tumor causing deformity. The average age of the patients was 10 years 5 months (range 4 to 13 years). There were 9 males and 2 females. The ADTA showed a statistically significant change with a p value of 0.0008 with a mean correction of 8.6 degrees (range of 2.3 to 15.6 degrees). The SDA demonstrated a mean correction of 15.4 degrees (range 0.3 to 41.8 degrees), p=0.002. The LDTA did not change significantly (p= 0.08), thus confirming no coincidental coronal plane deformity had occurred. 5 ankles required revision of fixation due to metalwork reaching its maximum limit of divergence at an average of 1 year. 2 ankles had screw pulled out due to osteolysis around the screw. There were no cases of infection. We report satisfactory short-term results of correction of calcaneus deformity using a flexible tension band plate and screws system.
1. Thirty-four cases of calcaneal osteotomy for mobile flat foot in nineteen patients are reviewed. 2. The function was markedly improved in seventeen of the nineteen patients. 3. The operation was successful in correcting the valgus deformity of the heel in thirty of the thirty-four feet. it was less successful in improving the longitudinal arch, especially when the flat foot deformity was severe.
Open reduction and reconstruction with osseous grafts (autologous grafts in 22 cases and heterologous grafts in 52 cases) were used in 74 cases. In 8 cases (all of Bohler II type) grafts weren’t used. Osteosynthesis with plate and screws was performed in 26 cases and with pins in 56. The 2 groups were similar in what concerns age, sex ratio, BMI, degree of comminution. The surgical procedure was delayed in both groups (average − 6 days). Pins were removed at 6 weeks and the plates at 12 months.
There are many reports of treatment for intraarticular fractures of the calcaneus using different methods. Results are very difficult to compare. For this reason a prospective study was designed to compare the outcome of the same type of fracture treated with Stein-mann pinning or plate osteosynthesis. Between January 1995 and March 1999 31 patients with two-part intraarticular fractures of the calcaneus, type IIB according to the Sanders classification, were treated operatively with either transcalcaneal pinning (12 fractures) or with open reduction and internal plate and screw fixation using a lateral approach (19 fractures). After a mean follow-up of 26 months all patients were assessed. A comparison was made between the two modes of treatment. The global score averaged 78.3 ± 12.1; 79.3 ± 11.14 for the patients treated with plate and screw fixation, and 76.6 ± 13.2 for the patients who underwent pinning. Lateral X-rays showed no difference in anatomical reduction between both methods. A positive correlation was demonstrated between the AOFAS Ankle-Hindfoot score and Böhler’s angle. The restoration of the congruity of the posterior subtalar joint was assessed postoperatively by means of a CT scan. The angle between the undersurface of the talus and the lateral fragment of the two-part fracture was evaluated. No statistically significant difference was found between both groups. The authors conclude that there is no difference in functional outcome between both modes of treatment. Plate osteosynthesis has the advantage that the shape of the hindfoot and midfoot is restored, but the higher complication rate is a drawback.